Cycle 1
Health 2024-10-17 · Fire 2024-10-17
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Sioux Falls, SD
Good Samaritan Society Luther Manor
2-star overall rating with 3-star inspections with $11,466 in total fines with 6 recent health deficiencies
1500 W 38th St, Sioux Falls, SD
(605) 336-1997
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
84
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1990-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.40
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,040
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9996
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.75
Baseline 20.92% · Performance 17.84% · Measure score 7.75 · Achievement 7.75 · Improvement 7.42
Healthcare-associated infections
5.07
Baseline 6.02% · Performance 6.32% · Measure score 5.07 · Achievement 5.07 · Improvement 0
Total nurse turnover
2.19
Baseline 60.98% · Performance 54.72% · Measure score 2.19 · Achievement 2.19 · Improvement 1.23
Adjusted total nurse staffing
3.50
Baseline 4.13 hours · Performance 4.07 hours · Measure score 3.50 · Achievement 3.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.07% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 6.67% · Lower 95% interval 6.66% |
| Discharge to community | 47.54% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 43.22% · Lower 95% interval 38.53% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.57% |
95.27%
0.7 pts worse
|
Numerator 87 · Denominator 92 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 92 |
| Discharge self-care score | 59.68% |
53.69%
6 pts better
|
Numerator 37 · Denominator 62 |
| Discharge mobility score | 61.29% |
50.94%
10.4 pts better
|
Numerator 38 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 4 · Denominator 92 · Adjusted rate 6.31% |
| Healthcare-associated infections requiring hospitalization | 6.32% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 3.08% · Lower 95% interval 2.96% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 81.2% |
42%
39.2 pts better
|
Numerator 108 · Denominator 133 |
| Discharge function score | 62.9% |
56.45%
6.4 pts better
|
Numerator 39 · Denominator 62 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 51.79% |
25.2%
26.6 pts better
|
Numerator 29 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.5
About the same
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.8 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
95.4%
0.2 pts worse
|
93.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.0% · Q3 90.8% · Q4 92.8% · 4Q avg 95.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
96.9%
1.8 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.4% |
5.1%
6.3 pts worse
|
3.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.9% · Q3 12.3% · Q4 13.0% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.6%
3.4 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.5%
0.4 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.9% · Q3 3.8% · Q4 8.8% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
17.8%
1.8 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 15.1% · Q3 15.1% · Q4 11.9% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
25.1%
6.3 pts better
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 18.6% · Q3 18.6% · Q4 16.7% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.6% |
21.3%
2.3 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 28.4% · Q3 18.5% · Q4 25.8% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
21.6%
3.4 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 25.5% · Q3 17.3% · Q4 28.8% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
2.0%
1.2 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
3.3%
2.7 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.6% · Q3 6.2% · Q4 9.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
25.8%
1.4 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 33.3% · Q3 24.6% · Q4 27.0% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
4.6%
4.1 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.0% · Q3 8.8% · Q4 3.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.8% |
83.2%
0.6 pts better
|
81.7%
2.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 93.7% · Q3 78.2% · Q4 75.3% · 4Q avg 83.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
11.7%
1.2 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 13.6% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.7%
0.7 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 2.9% · Q4 2.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.0% |
78.2%
14.8 pts better
|
79.7%
13.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.0% |
21.5%
8.5 pts worse
|
23.9%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.0% · Observed 30.5% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-26 · Fire 2022-10-26
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-10-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-15
G · Actual harm
2025-06-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-15
G · Actual harm
2024-10-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-10-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-12
E · Potential for more than minimal harm
2023-09-08
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-09-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-09-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-26
E · Potential for more than minimal harm
2022-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-23
Penalties and ownership
What sits behind the stars
$11,466
2024-10-17
Fine
Fine · fine $11,466
Fine
Ownership
Cain, James
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Guyse, Kelli
W-2 Managing Employee · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
W-2 Managing Employee · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Orstad, Keri
Contracted Managing Employee · Individual
Rogers, Michael
Corporate Officer · Individual
Sanford
5% Or Greater Direct Ownership Interest · Organization
Schema, Nathan
Corporate Officer · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
The Evangelical Lutheran Good Samaritan Society
Operational/Managerial Control · Organization
Ventling-Herrmann, Marnie
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Avantara Norton
Sioux Falls, SD
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $191,055 in total fines with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Bethany Home Sioux Falls
Sioux Falls, SD
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Society Sioux Falls Village
Sioux Falls, SD
1-star overall rating with 1-star inspections with $72,644 in total fines with 14 recent health deficiencies
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